Affidavit of Loss - Vaccination Card
Affidavit of Loss - Vaccination Card
Affidavit of Loss - Vaccination Card
AFFIDAVIT OF LOSS
1. Last August 11, 2021, I took my first dose of Sinovac Vaccine at J Centre Mall
vaccination facility;
2. In view of such, I was issued a vaccination card bearing my identity as well as the
date and the vaccine shot I take;
3. The aforesaid Vaccination Card was usually placed inside the brown envelope
together with my all other documents;
4. I was scheduled to take my 2nd dose of vaccine this coming September 13, 2021 at the
same venue;
5. Unfortunately, last week while I was preparing the said Card, I found out that the
said Vaccination Card was no longer found inside the brown envelope ;
6. Immediately, I exerted diligent efforts to trace and locate the aforesaid Card but to
no avail. Hence, it is considered lost for all intents and purposes;
7. In the event that the said Vaccination Card should thereafter be found or recovered, I
undertake to forward or surrender the same to the authorities for its appropriate
disposal;
8. I execute this affidavit to attest to the veracity of the foregoing statements, and to
report the loss of the said item so I can be issued with a new Vaccination Card and
for whatever legal purpose this may best serve.
Doc No.____;
Page No.____;
Book No.____;
Series of 2021.